Remote Utilization Management Nurse

Mass General Brigham Health Plan, Inc.; Somerville (MA); Remote; USD 59,000 - 142,000; Full time

Job summary

Mass General Brigham Health Plan in Somerville, MA is seeking a clinical RN with UM experience to provide escalation support and triage inquiries, evaluating medical necessity and ensuring adherence to guidelines. You will collaborate with Nurse Reviewers, Medical Directors, and interdisciplinary teams to facilitate timely determinations.

The role emphasizes patient-centered care, regulatory compliance, and closure of complex cases.

Qualifications

• Associate's Degree in Nursing required or Bachelor's Degree in Nursing preferred.
• Massachusetts RN license.
• BLS certification preferred.
• 2–3 years of case management, utilization review, or discharge planning experience preferred.

Responsibilities

• Serves as the primary point of contact for escalation utilization management inquiries, ensuring timely triage, assessment, and resolution of complex provider, member, and internal stakeholder requests.
• Reviews and responds to escalated authorization, coverage determination, and service-related issues, coordinating with Nurse Reviewers, Medical Directors, and operational teams to facilitate appropriate next steps and ensure regulatory compliance.
• Monitors escalation channels, including phone calls, shared inboxes, ticketing systems, and other referral pathways, prioritizing requests based on clinical urgency, regulatory requirements, and business impact.
• Provides consultation and clinical guidance to utilization management staff regarding benefit interpretation, medical necessity criteria, workflow processes, and resolution of complex or sensitive cases.
• Identifies trends, recurring issues, and process improvement opportunities through escalation review activities, collaborating with leadership and cross-functional partners to enhance operational efficiency, provider experience, and member outcomes.

Skills

Active listening

Logical reasoning

Rapport building

MS Office

Problem solving

Confidentiality

Healthcare knowledge

Education

Nursing degree (ADN or BSN)

Tools

Microsoft Office

Job description

Mass General Brigham Health Plan in Somerville, MA is seeking a clinical RN with UM experience to provide escalation support and triage inquiries, evaluating medical necessity and ensuring adherence to guidelines. You will collaborate with Nurse Reviewers, Medical Directors, and interdisciplinary teams to facilitate timely determinations.

The role emphasizes patient-centered care, regulatory compliance, and closure of complex cases.